Author Archives: Jason Schwartz
Drugfree.org has a piece advocating more use of buprenorphine with children.
Medication-Assisted Treatment (MAT) for opioid dependence is a science-based and proven-effective option for teens and young adults. It should be administered with age appropriate psychosocial therapy and drug testing. Unfortunately, it has been subject to controversy and stigma. Yet the neuroscience of addiction and cravings helps explain why MAT, when properly used and overseen, can be truly life saving for adolescents, young adults, and their families. I see it working all the time. When kids come into treatment, their lives are just chaotic. Parents are desperate — they don’t know what to do or where to turn. The most important thing is to bring stability into the situation, and the best way to do that is with medication.
So now we’re expanding the notion of incapacitating long-term brain changes to adolescents? Who have been using in what quantities? And, for how long? (Apparantly the only people with brains that aren’t permanently disabled by opiate addiction are health professionals. They get abstinence focused treatment and have outstanding outcomes.)
My first thought about the piece was, “Hey, at least he provides some actual numbers.” However, upon closer examination, though the numbers give the appearance of an accountable professional engaging in informed consent, something’s not kosher here.
In our highly-structured program at Boston Children’s Hospital about a third of the children remain completely free from any alcohol and drug use. About another third remain free from opioid use but they might have an occasional slip on alcohol or marijuana. (We tend to not approve of that behavior and keep working with them). And the remaining third, particularly early on, will try opioids once or twice. But even after those early slips they show dramatic improvement over time.
Unfortunately, he doesn’t provide any timeframe. AND, stop and think about the numbers he offered:
- 1/3 free of alcohol and drug use
- 1/3 use no opioids but occasionally use alcohol or marijuana
- 1/3 use opioids “once or twice”
1/3 + 1/3 + 1/3 = 100%
He is saying that approximately 100% will not use opioids 3 or more times? This is an eminent physician at a prestigious institution. He has been a Principal Investigator of studies on adolescent substance abuse funded by the National Institute on Alcohol Abuse and Alcoholism (NIAAA), the National Institute on Drug Abuse (NIDA), the Substance Abuse and Mental Health Services Administration, and the Robert Wood Johnson Foundation.
This assertion is so obviously implausible that it should provoke deep skepticism about the people upheld as experts, the funding priorities of government agencies and the biases built into what become “evidence-based practices.” (Remember “no hint of opinion“?)
As you read the comments, you’ll find people complaining about the methadone not being included. (Methadone for adolescents!)
You’ll find one comment, from a physician, explaining that, “Dr. Knight works with adolescents, with most of his patients under age 16, where methadone cannot legally be used (under 18 can be used with parental consent).”
The author’s finger wagging, very certain tone is regarding the use of Suboxone with patients under the age of 16.
I can imagine circumstances where the best path is not crystal clear (I’m thinking of youth that are highly resistant to treatment and at high risk for fatal OD.) but the question any family has to ask is, “How do we want my loved one to return too us?”
Here are Earl Hightower and Anna David:
AD: Should the parents just accept the first recommendation or should they ask for more?
EH: I think the first question they should ask should be one they ask themselves, which is how they want their son to return.
AD: What does that mean?
EH: Well, the majority of the treatment centers out there are 12-step based, which means that the goal for them is for their clients to achieve abstinence. This would be the choice to make if the parents want to get their son back in the same condition that he was in before he got on drugs: drug-free.
AD: But you can’t say for certain that a 19-year-old who was doing Oxy for nine months is definitely an addict who will need 12-step.
EH: You can’t. Maybe he was just dabbling; treatment would be able to help determine that. But maybe treatment will prove something else—maybe treatment will prove that this wasn’t an isolated incident. Maybe he’ll get in there and confess that he’s been using pot since he was 12 and maybe other conversations will turn up the fact that there’s a genetic predisposition toward addiction in the family. And if that’s the case, I believe he will need community-based support in staying clean once he returns home. It could go either way: good ongoing clinical assessment is the backbone of early treatment to determine the direction of care.
AD: But not all rehabs recommend 12-step or even full abstinence.
EH: Yes. And that’s why parents—people—need to know is that if an addict is going to a facility which subscribes to medication-assisted treatment and recovery, the goal is different. Loved ones need to know what medication-assisted treatment really means, which is that treatment will be radically re-defined and their child could be put on a medication which he would remain on for a long time, if not the rest of his life.
AD: So that’s what you mean when you talk about parents asking themselves how they want their child to return.
EH: Yes. But I can tell you from 30 years of doing this work that most parents want their child to come home drug-free—or they at least they want a shot at that. But some members of the treatment community will tell parents—or the addicts themselves—that we have to let go of this notion of abstinence and move more in the direction of medication-assisted treatment. And that means that people who could thrive without being on anything at all are leaving treatment centers on very powerful opiate replacement drugs.
This week’s tribe is Millati Islami:
Millati Islami is a fellowship of men and women, joined together on the “Path of Peace”. We share our experiences, strengths, and hopes while recovering from our active addiction to mind and mood altering substances.
We have sought to integrate the treatment requirements of both Al-Islam and the Twelve Step approach to recovery into a simultaneous program. Our personal thanks and appreciation goes to the Narcotics Anonymous and Alcoholics Anonymous programs from which we borrowed. Just as Narcotics Anonymous was founded out of its need to be non-specific with regard to substance, so Millati Islami was born out of our need to be religiously specific with regard to spiritual principles.
Millati Islami, by G-d’s will, (masha-Allah) offers a fresh perspective on age old ideas for treating our fallen human conditions. We pray further that it will serve as a model for successfully understanding and addressing the special problems encountered as recovering Muslims and substance abusers in a predominately non-Muslim society.
(The “Tribes of the recovering community” series is intended to demonstrate the diversity within the recovering community.I have no first hand knowledge of most of the tribes, so inclusion in this series should not be considered an endorsement.)
- Tribes of the recovering community (addictionandrecoverynews.wordpress.com)
- Tribes of the recovering community (addictionandrecoverynews.wordpress.com)
- Tribes of the Recovering Community (addictionandrecoverynews.wordpress.com)
These images speak for themselves. Here are a couple of important sentences:
Between 1999 and 2009, drug poisoning deaths grew by 394 percent in rural areas and 279 percent for large metropolitan areas, according to the CDC’s county-level look at the data.
According to the CDC, roughly 60 percent of all OD deaths in 2010 were caused by prescription drugs, with three-fourths of those cases involving painkillers.
The work of advocates like these is growing more important.
- Drug Overdose Deaths Are Increasing Pretty Much Everywhere (motherboard.vice.com)
- Drug Poisoning Deaths Have Tripled in the Last 30 Years (usnews.com)
Bill White introduces a new concept, precovery:
Precovery involves several simultaneous processes: physical depletion of the drug’s once esteemed value, cognitive disillusionment with the using lifestyle (a “crystallization of discontent” resulting from a pro/con analysis of “the life”), growing emotional distress and self-repugnance, spiritual hunger for greater meaning and purpose in life, breakthroughs in perception of self and world, and (perhaps most catalytic in terms of reaching the recovery initiation tipping point) exposure to recovery carriers–people who offer living proof of the potential for a meaningful life in long-term recovery. These precovery processes reflect a combustive collision between pain and hope.
Unfortunately, it can often take decades for these processes to unfold naturally. If there is a conceptual breakthrough of note in addictions field in recent years, it is that such processes can be strategically stimulated and accelerated. Today, enormous efforts are being expended to accelerate precovery processes for cancer, heart disease, diabetes, asthma, and other chronic disorders. We as a culture are not waiting for people to seek help at the latest stages of these disorders at a time their painful and potentially fatal consequences can no longer be ignored. We are identifying these disorders early, engaging those with these disorders in assertive treatment and sustained recovery monitoring and support processes. Isn’t it time we did the same for addiction?
This made me think of Debra Jay and her efforts to continue refining, improving and expanding the role of family interventions.
Boston University recently posted a series on their own addiction research. One examined whether there is a relationship between taking ADHD meds and future cocaine use.
The results of Kantak’s research could present a dual cautionary tale for adolescents diagnosed with ADHD. “If they’re an adolescent getting a stimulant medication, and they’re properly diagnosed, the medication may put them at increased risk” for cocaine use as an adult, Kantak says. “If they’re misdiagnosed, and get Strattera, this may also be putting them at greater risk…of acquiring an addiction to cocaine.”
Kantak’s bottom line? She thinks adolescents properly diagnosed with ADHD should take either Strattera or another nonstimulant medication, while those whose diagnosis is doubtful would be wise to stay away from Strattera. She also believes pediatricians need to be especially careful when arriving at diagnoses. At the same time, she cautions parents who may see certain symptoms and “convince themselves that their child has ADHD, while what they really want is to give them a better competitive edge.” That edge could have dire circumstances down the line.
This is especially concerning, given the high rates of ADHD diagnosis. From the CDC:
- Approximately 11% of children 4-17 years of age (6.4 million) have been diagnosed with ADHD as of 2011.
- The percentage of children with an ADHD diagnosis continues to increase, from 7.8% in 2003 to 9.5% in 2007 and to 11.0% in 2011.
- Boys (13.2%) were more likely than girls (5.6%) to have ever been diagnosed with ADHD.
- Prevalence of ADHD diagnosis varied substantially by state, from a low of 5.6% in Nevada to a high of 18.7% in Kentucky.
- One in Five Diagnosed ADHD May Develop Cocaine Habit as Adults (madinamerica.com)
- Is ADHD Overdiagnosed? Disorder’s Broad Definition Could Subject Kids To ‘Unnecessary’ Treatment (medicaldaily.com)
Jennifer Matesa has a new piece up at the recently reincarnated The Fix. It’s a response to the recent NY Times series on Suboxone and goes directly after the underlying assumption and its implications for her.
Reckitt can get away with convincing doctors that addicts need to be maintained on Suboxone because—as the Times story notes—common belief holds that painkiller addicts can never be drug-free. We’re told we’ve permanently screwed up our neurology. Popular thinking goes: Once you junkies take drugs, you might as well stay on drugs for life.
To support this belief, Reckitt and its growing army of reps offer twisted interpretations of research studies and anecdotal evidence about addiction and Suboxone. They claim studies “prove” that replacing painkillers with buprenorphine (the opioid drug in Suboxone) helps us stay “clean.” Ditch the old drug for the new drug and we stop shooting, snorting, stealing, doctor-shopping, tricking.
. . .
If my “Sub doc” had believed—as so many doctors do—that somebody like me could never be drug-free, I’d without a doubt still be on drugs today. Hell, which of us inside active addiction believes we can do without drugs? I’d also be experiencing nasty side-effects for which people who read my addiction-and-recovery blog write in asking for help.
For me, what’s so important about her voice is that she’s one addict speaking directly to other addicts around the chorus of experts chanting, “research shows that maintenance treatments are the most effective treatments we have.” She’s offering hope that other addicts don’t have to limit themselves to the definition of success that these experts offer (reduced death, disease and drug use).
She’s also become a collector of stories about the lived experience of people who have tried Suboxone and found it to be incompatible with full recovery and very difficult to discontinue.
Just like doctors who can’t detox their patients off painkillers, most doctors who prescribe Suboxone don’t know how to help their patients quit. So the patients wind up asking me to be their doctor. One woman recently begged me to manage her detox in exchange for payment. I declined, but I was left shocked at the desperation of some folks out there to live a drug-free life, so much so that they will contact a total stranger and offer cash for an amateur detox. This speaks to the sorry state of treatment (not to mention the general health-care system) in this country.
These folks read my blog, they know I got off drugs including Suboxone, and they can see I’m living a productive drug-free life. I write them back, but I can’t be their doctor. The best I can do is keep writing stories like these, and letting policymakers, researchers, and practitioners know that they need to open their minds about how well most addicts can live, how much we can heal.
- “a hopeless disease” (addictionandrecoverynews.wordpress.com)
- Two more defenses of Suboxone (addictionandrecoverynews.wordpress.com)
- Addiction Treatment With a Dark Side (addictionandrecoverynews.wordpress.com)
- NY Times / Suboxone redux (addictionandrecoverynews.wordpress.com)
- At Clinics, Tumultuous Lives and Turbulent Care (nytimes.com)
- NYT Reax (addictionandrecoverynews.wordpress.com)
- Who’s guarding the hen house? (addictionandrecoverynews.wordpress.com)
From the UK Advisory Council on the Misuse of Drugs second report of the recovery committee [emphasis mine]:
…our optimism about recovery should be tempered. Evidence suggests that different groups are more or less likely to achieve recovery outcomes. For some people, with high levels of recovery capital (e.g. good education, secure positive relationships, a job), recovery may be easier. For others, with little recovery capital or dependent on some types of drugs (especially heroin), recovery can be much more difficult and many will not be able to achieve substantial recovery outcomes.
It’s great that people are discussing recovery and looking at outcomes, but I have a few important concerns.
At what point does recovery capital become a proxy for class?
I’m increasingly concerned that recovery capital is becoming a proxy for social class. Whenever I discuss health professional outcomes, the typical response is something like, “Yeah, well, they have a lot more recovery capital than most opiate addicts.” The implication is that health professionals (and people like them) are capable of achieving drug-free full recovery while other opiate addicts are not. This is particularly troubling as maintenance becomes the de facto treatment for opiate addiction and significant financial resources become more important for accessing drug-free treatment of adequate duration and intensity. (Like health professionals get.)
This question brings John Rawls and his “original position” to mind.
In the original position, the parties select principles that will determine the basic structure of the society they will live in. This choice is made from behind a veil of ignorance, which would deprive participants of information about their particular characteristics: his or her ethnicity, social status, gender and, crucially, Conception of the Good (an individual’s idea of how to lead a good life). This forces participants to select principles impartially and rationally.
We have a situation where the experts provide one kind of treatment to their peers and another kind of treatment to the rest of their patients. If these experts had to assume the original position and operate from behind the veil of ignorance–if they were to be reborn an addict of unknown class, race, gender, economic status, etc–what would they want the de facto treatment to be?
If it’s not maintenance, then we have a social justice problem.
Evidence for what?
The other important question concerns the evidence. I have several questions about discussions about evidence.
- How many of these experts view opiate addiction as a hopeless condition?
- Do the experts and evidence address quality of life?
- How many of the experts have an anti 12-step bias or anti-recovery bias?
- How many of the experts receive payments from drug companies or have other financial interests in the drugs they are researching?
- Do the experts recognize the limitations of evidence in making policy?
- Are we getting all of the evidence?
- What influence is PHARMA wielding?
- Evidence for what outcomes?
“If you have come here to help me, then you are wasting your time…
But if you have come because your liberation is bound up with mine,
then let us work together.” - Lila Watson
Obviously, I’ve been thinking a lot about the buprenorphine maintenance, the NY Times series and the reactions since it was published.
At Dawn Farm, we’ve often said that maintenance approaches are rooted in the belief that opiate addicts can’t recover. Now, I’m the kind of person who tends to be uncomfortable making statements that claim to know the contents of another person’s mind. This week has made me much more comfortable with that statement. None of the responses have argued that maintenance is a great tool for achieving recovery. Several have referred to opiate addiction as a hopeless condition. All the arguments for it have been harm reduction arguments–that it’s associated with reduced use, overdose death, disease transmission, crime and incarceration. (The data is less compelling than many of them would have you believe.)
I want to make clear that I have no interest in getting between an addict and a maintenance treatment. All I want is a day when addicts are offered the same treatment that their doctors are offered–recovery oriented treatment of an adequate duration and intensity. I have no problem with drug-assisted treatment being offered. Give the client accurate information and let them choose.
However, when we have professionals, policy makers and researchers who don’t believe in the capacity of patients to recover, the kind of help they are going to offer is going to be unhelpful. They’ll focus on risk factors for overdose like “compromised tolerance”. Of course, decreased tolerance is associated with overdose. Then again, social interaction is associated with transmission of many illnesses. Should we discourage social lives?
One has to wonder if the experts interviewed for these articles know any addicts in full recovery–people who are fully re-engaged in family life, community life, vocations, education, faith communities, etc. If so, do they think of the people they know as belonging to some special category that makes them different from other addicts? (When I teach about addiction and bring up the outcomes for health professionals, many students argue that they are a different kind of addict and better outcomes are to be expected.)
While I don’t want to take choices away from addicts, their’s a big part of me that wants these “experts” to leave us alone. We don’t need your “help.” (A kind of help you would never offer a sick peer.)
That sentiment brings to mind this Malcolm X story:
Several times in his autobiography, Malcolm X brings up the encounter he had with “one little blonde co-ed” who stepped in, then out, of his life not long after hearing him speak at her New England college. “I’d never seen anyone I ever spoke before more affected than this little white girl,” he wrote. So greatly did this speech affect the young woman that she actually flew to New York and tracked Malcolm down inside a Muslim restaurant he frequented in Harlem. “Her clothes, her carriage, her accent,” he wrote, “all showed Deep South breeding and money.” After introducing herself, she confronted Malcolm and his associates with this question: “Don’t you believe there are any good white people?” He said to her: “People’s deeds I believe in, Miss, not their words.”
She then exclaimed: “What can I do?” Malcolm said: “Nothing.” A moment later she burst into tears, ran out and along Lenox Avenue, and disappeared by taxi into the world.
I can relate to his sentiment that the most helpful thing others can do is leave us alone. (“Other” can be a pretty ugly word, no?) Then, when I’m a little less emotional, I’m left to consider my own cognitive biases and creeping certitude. I have to think about the contributions of people like Dr. Silkworth, Sister Ignatia, George Vaillant, etc.
Malcolm X had a similar experience to this too:
In a later chapter, he wrote: “I regret that I told her she could do ‘nothing.’ I wish now that I knew her name, or where I could telephone her, and tell her what I tell white people now when they present themselves as being sincere, and ask me, one way or another, the same thing that she asked.”
Alex Haley, in the autobiography’s epilogue (Malcolm X had since been assassinated), recounted a statement Malcolm made to Gordon Parks that revealed how affected he was by his encounter with the blonde coed: “Well, I’ve lived to regret that incident. In many parts of the African continent I saw white students helping black people. Something like this kills a lot of argument. . . . I guess a man’s entitled to make a fool of himself if he’s ready to pay the cost. It cost me twelve years.”
Malcolm X realized, too late, that there was plenty this “little blonde coed” could have done, that his response to her was inconsistent with what he, his associates, and his followers wanted to accomplish.
Bill White wrote about the things that have allowed practitioners to avoid the cultural traps in working with addicts:
Four things have allowed addiction treatment practitioners to shun the cultural contempt with which alcoholics and addicts have long been held:
- personal experiences of recovery and/or relationships with people in sustained recovery,
- addiction-specific professional education,
- the capacity to enter into relationships with alcoholics and addicts from a position of moral equality and emotional authenticity (willingness to experience a “kinship of common suffering” regardless of recovery status), and
- clinical supervision by those possessing specialized knowledge about addiction, treatment and recovery processes.
We must make sure that these qualities and conditions are not lost in the rush to integrate addiction treatment and other service systems.
I don’t know how to engage these experts who may know a lot about the illness, but appear to be blind to the fact that full recovery already exists in every community across the country. It’s especially tough when the field is so fractured, there’s so much money to be made, and external forces (like the Affordable Care Act) are going to be pushing addicts toward primary care for their treatment.
As far as Dawn Farm goes, I heard something last week that cast us in a new light for me.
“We are unapologetically rooted in culture.
If you want to join us, and you’re not part of that culture,
you need to find ways to respect, honor and celebrate that culture.” - Dan Floyd
We’ve talked a lot about the concept of cultural competence and that professional helpers need to deliberately develop similar competencies when working with addicts and the recovering community. I still believe this is true. But, at Dawn Farm, we go beyond mere competence. We are rooted in the culture of recovery, and we help non-recovering staff (more than half of our staff) find ways to respect, honor and celebrate that culture.
This puts us out of the mainstream among professional helpers and “experts” on addiction, but we wouldn’t change a thing.
The question is how to develop this kind of competence in these researchers, policy makers and experts. It would seem that recovery advocacy would be an important way to do this. However, drug manufacturers have ingratiated themselves with recovery advocacy organizations and the organizations have tried to ingratiate themselves with experts. As a result, they’ve waded into supporting medication assisted recovery, but have done little to challenge the therapeutic nihilism that PHARMA nurtures and is a theme in the public comments of these experts.
In the meantime, this brings me back to the quote I opened this post with.
“If you have come here to help me, then you are wasting your time…
But if you have come because your liberation is bound up with mine,
then let us work together.” - Lila Watson